Motivational interviewing and the decisional balance procedure for cessation induction in smokers not intending to quit

Introduction The decisional balance (DB) procedure examines the pros and cons of behavior change and was considered a component in early formulations of Motivational Interviewing (MI). However, there is controversy and conflicting findings regarding the use of a DB exercise within the treatment of addictions and a need to clarify the role of DB as a component of MI. Methods College tobacco smokers (N = 82) with no intentions on quitting were randomly assigned to receive a single counseling session of either Motivational Interviewing using only the decisional balance component (MIDB), or health education around smoking cessation (HE). Assessments were obtained at baseline, immediately post-treatment, 1 week, and 4 weeks. Results Compared to HE, the MIDB sessions scored significantly higher on the Motivational Interviewing Treatment Integrity (MITI) scale (all standardized differences d > 1, p < 0.001). Unexpectedly, self-report Pros of smoking scores increased for MIDB but decreased for HE (MIDB vs HE standardized difference d = 0.5; 95%CI 0.1 to 1.0, p = 0.021). Both groups showed significant reductions in smoking rates and increases in motivation to quit, quit attempts, and self-reported abstinence, with no significant group differences. Changes in the Pros of smoking were correlated with MITI scores, but not with cessation outcomes. In contrast, increases in the Cons of smoking and therapeutic alliance were predictive of better cessation outcomes. Conclusions The decisional balance exercise as formulated by earlier versions of MI may be counter-productive and cautions around its use are warranted. Instead, improved cessation outcomes appear associated with increasing perceived benefits of quitting and positive therapeutic alliance.